Presbyterian Healthcare Services Care Management

Transcription

1 Presbyterian Healthcare Services Care Management Kathy M. Garcia RN, BSN Director of Nursing, Primary Care Service Line November 2012

2 Future Healthcare Challenges Increasing number of patients Decreasing numbers of Primary Care Physicians Increasing health care cost Decrease in funding

3 Care Management- Goals & Objectives Increase access to services Improve the quality of health care Deliver better care at a lower cost Improve the customer experience Improve the health of populations

4 Patient Centered Medical Home Medical Home Joint Principles: (AAFP, ACP, AAP)

5 PCMH: Foundation Overview Milestones Advanced Access Lean Electronic Medical Record (EMR) Behavioral Health Integration Deployed Advanced Access principles to match supply and demand, reduce backlog, simplify appointment types and lengths, create contingency plans, reduce demand for unnecessary visits, and optimize the care team to improve access for patients. Implemented Lean principles with a focus on the delivery of medical care to decrease delays, eliminate waste, and decrease rework. Implemented an ambulatory electronic health record and patient portal to increase patient safety, promote the use of evidencebased medicine, improve quality, and promote continuity of care. The EMR serves as a disease registry to support proactive patient outreach. Behavioral health services were integrated into the primary care settings to support early identification and intervention for mental health needs

6 PCMH: Expanded Care Team Primary Care Provider Primary Nurse/MA Team Nurse Behavioral Health Clinician Pharmacist Clinician Certified Diabetic Educator Nurse Navigator Case Manager

7 PCMH: Alternative Venues of Care Telephone Appointments - Primary Care Provider - Acute Needs - No Copay Group Visits Disease Management - PCP Intervention - Patient Education - Peer Support MyChart- Patient Portal - Secure Messaging - Appointment Requests - RX Refill Request - Referral Request - Test Results - Visit History -

8 Presbyterian Primary Care- Diabetes Management Workflow Primary Nurse/MA Visit Preparation Patient with Dx-Diabetes is scheduled for an office visit with PCP Primary Nurse/MA takes action on EMR- Best Practice Alert(s) to cue up orders for A1c, Fasting Lipid Panel, and BP measurement and removes patient s shoes for Diabetic Foot Exam, when applicable. Primary Nurse/MA completes POCT for A!C and obtains BP measurement If BP measurement is 140/80 or higher, Primary Nurse/MA flags patient for repeat BP measurement If second BP measurement continues to be 140/80 or higher, Primary Nurse/MA cues up ACE/ ARB medication order on behalf of PCP. Medication order is routed to PCP Inbasket for review and co-signature. Primary Nurse/MA documents A1C and BP value(s) in EMR Patient Outreach locates Diabetes Management -Patient List in EMR Reporting Workbench contacts patient by telephone/ contacts letter patient to notify by patient telephone/ of letter pending to notify orders patient of pending orders reviews report to identify patients with potential Diabetes Management needs uses telephone interaction to assess patient for additional diabetes needs reviews patient s past medical history in EMR-Chart Review to confirm Diabetes Management needs initiates care team referral(s) as appropriate (refer to Care Management Protocol) refers to Diabetes Care Management Protocol to initiate orders consults with PCP when additional intervention is required cues up order(s) in the EMR on behalf of the PCP documents intervention(s) in EMR Telephone Encounter Patient order(s) are routed to PCP Inbasket for review and co-signature monitors patient, as appropriate Team Nurse Nurse Visit Follow-Up PCP or identifies diabetes management need i.e. Diabetes Foot Exam, POCT- A1C, Blood Glucose Monitor Teaching, and/or patient education schedules Nurse Visit for Diabetes Management order(s) Team Nurse reviews order(s) in EMR prior to Nurse Visit and clarifies PCP order(s), when needed Team Nurse reviews PCP order(s) with patient, completes order(s) as indicated in EMR Team Nurse documents intervention(s) in Nurse Visit Encounter Last Updated kagarcia

9 Percentage Population Count of Diabetics PCMH: Improved Patient Outcomes 2012 Diabetes Bundle Diabetic D3 Bundle Performance YTD Jan-11 Mar-11 May-11 Jul-11 Sep-11 Nov-11 Jan-12 Mar-12 May-12 Jul-12 Sep Diabetic Patient Count D3 Bundle %

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